2017-‐ 2018 ENROLLMENT APPLICATION FORM Mail or fax to: Registrar, Charter Office, 325 Marion Ave. Ben Lomond, CA 95005 Phone (831) 336-‐5167 or Fax (831) 336-‐0131 Email to
[email protected] If you have any questions, please call (831) 336-‐5167
Please check the program
you prefer to participate in
☐QH Homeschool (K-‐8) ☐QH Integrated Arts (7-‐8) ☐Fall Creek Homeschool (K-‐5) ☐Mountain I/S (in Soquel)
☐Coast Redwood Middle School ☐Coast Redwood High School ☐Nature Academy* *Lottery application required
Do not disenroll from your current school until you have met or spoken to someone from the Charter Office The submission of this application does not constitute enrollment.
Student Last Name First Name Legal Alias(s) Birth Date Birth City Home Phone Cell Phone School District of Residence
MI
Gender Nickname or other
Current Grade
Birth State
Birth Country
Emergency Contact: Name
Emergency Phone Number
County of Residence
(Circle one)
Name (Last, First):
Mother/Guardian
Parent / Guardian Information Father/Guardian
__________________________________________ ______________________________________
Work Phone
(_______)__________________________________ (_______)_____________________________________
Home Phone
(_______)__________________________________ (_______)_____________________________________
E-‐mail Address: __________________________________________ _____________________________________________ Mailing Address: _________________________________________ City:__________________________Zip:_____________ Residential Address: __________________________________
City:__________________________Zip: _____________
Education Level: Graduate school/post graduate training Graduate school/post graduate training College Graduate Some college/AA Degree College Graduate Some college/AA Degree High School Graduate Not a High School Grad High School Graduate Not a High School Grad
☐︎ Navy ☐Air Force ☐Marine Corps Is either parent/guardian on active duty in the US armed forces? ☐ Army . or ☐ Coast Guard or ☐ on full-time National Guard Duty ☐ YES ☐NO
. School Information ................................................................................Previous . . ________________________________________________________ _____________________________________________________ Previous School Name Previous School Address Please list, in order of priority, your needs from this school. 1. . 2. . 3. Please complete back of form
Additional Student Information Ethnicity: Hispanic/Latino: ___Y ___N 100-‐ American Indian/Alaska Native 600-‐Black or African American 700-‐White
Check All that Apply. If multiple, please circle the primary: 201-‐Chinese 205-‐Asian Indian 202-‐Japanese 206-‐Laotian 203-‐Korean 207-‐Cambodian 204-‐Vietnamese 208-‐Hmong
299-‐Other Asian 301-‐Hawaiian 302-‐Guamanian 303-‐Samoan
304-‐Tahitian 399-‐Other Pacific Islander 400-‐Filipino
Language Survey What language did your child first learn to speak: _________ Which language does your child most frequently use at home: ____ Which language do you most frequently speak to your child: _______ Which language is spoken most often to your child: ______ ALL Applicants must complete A. & B. questions below: Special Education Section A. Has your child ever been referred and/or evaluated to receive special education services such as Speech, RSP, SDC, Adaptive PE, Ot, PT, 504 Plan? Yes No B. Has your child ever attended a Special Education Class? Yes No If YES to either question, complete questions 1-‐5 below. 1. Does your child have a current/active IEP? YES/NO (If NO, what was the date of his/her last IEP __________) 2. School name and address where special education referral, assessment or IEP was developed* _____________________________________________________________________________________________________ 3. Date of most recent IEP*: ______________ *Enclose a copy of your child’s most recent IEP with this application. If your child does not have an IEP, but was evaluated for special education, enclose a copy of all assessment reports. IMPORTANT ENROLLMENT INFORMATION: Remember, the student is not enrolled or committed to enrollment by completing this application, but is requesting an enrollment appointment with one of our Teachers where enrollment decisions and start dates will be discussed. Do not disenroll from your current school until you have heard from our registrar! DOCUMENTS required to be submitted along with the Enrollment Application form: (Please attach/fax required documents to/with this application. Applications received without the required documentation will be returned and must be resubmitted.) Check if included: Copy of Birth Certificate (required for all applicants) Copy of Immunization Card, AND mandatory proof of Tdap/Whooping Cough Booster on or after 7th birthday (required for all applicants) Report of Health Exam for School Entry (Required for K and 1st grade students attending public school for the first time) Report of Oral Health Exam for School Entry (Required for K and 1st grade students attending public school for the first time) Most recent copy of child’s IEP, active or inactive. If child does not have an IEP, but was evaluated for special ed, enclose a copy of all assessment reports. Trasncript copy (if high school level) th th CAHSEE scores (11 to 12 grade only) Caregiver Authorization Affidavit (if person enrolling student is NOT the parent or legal guardian) I acknowledge that enrollment with the SLVUSD Charter School is voluntary. ______________________________________________________ ______________________________________ Parent/Guardian Signature Date
